Blinded comparison of preoperative duplex ultrasound scanning and contrast arteriography for planning revascularization at the level of the tibia

PURPOSE: We examined whether preoperative duplex ultrasound scanning (DU) could replace contrast material-enhanced arteriography (CA) in selecting the recipient artery of tibial or peroneal artery bypass grafts. METHODS: In patients who underwent tibial or peroneal artery bypass grafting because of critical ischemia, images were obtained of the lower extremity arterial circulation with both DU and CA. Vascular surgeons, blinded to the operation performed, reviewed either DU or CA images for arterial visualization and patency. The tibial or peroneal artery best suited to receive the bypass graft was selected by surgeons using only data from either DU or CA images. This selection was compared with the artery actually used at bypass surgery. RESULTS: Preoperative DU and CA data for 40 lower extremities in 38 patients undergoing bypass grafting at the level of the tibia provided 110 arteries: 38 anterior tibial arteries, 32 peroneal arteries, and 40 posterior tibial arteries. Ten arteries (8 peroneal, 2 anterior tibial) were not identified with DU, and 1 artery (anterior tibial) was not identified with CA. DU enabled prediction of the artery actually used in 88% of patients (35 of 40), whereas CA enabled prediction of the artery actually used in 93% of patients (37 of 40; P =.59). Duplicate findings at DU and CA enabled selection of 85% of arteries actually used (95% confidence interval, 71%-93%). Arteries used for bypass grafting had significantly higher peak systolic velocity (35 cm/s vs 25 cm/s; P =.04), higher end-diastolic velocity (15 cm/s vs 9 cm/s; P =.005), and greater diameter (2.4 mm vs 1.7 mm; P =.003) compared with arteries not selected for bypass grafting. CONCLUSION: Findings at DU and CA typically agree when used to select tibial or peroneal arteries for bypass grafting. With DU there is occasional difficulty in identification of the peroneal artery, but selection of the actual artery used is accurate. Peak systolic velocity, end-diastolic velocity, and diameter characteristics correlate with arteriographic criteria for tibial bypass target artery selection. If DU enables adequate identification of a target artery for bypass grafting, and especially if the peroneal artery is seen, findings at CA are not likely to alter bypass execution.     

56例腘动脉以下肢体动脉缺血的血管重建术分析

目的总结腘动脉水平动脉闭塞血运重建术治疗的临床疗效。方法对2001年7月至2005年8月56例累及腘动脉及腘动脉以下三分支病变重建肢体血运进行回顾性分析。根据病变阻塞平面不同,采用不同的血管架桥,对多平面、多节段动脉闭塞采用聚四氟乙烯人工血管和自体静脉桥复合序贯架桥血运重建。结果术后平均随访17个月,移植血管一期通畅率67．3％,二期通畅率78．8％。结论复合序贯搭桥术治疗累及股浅-腘动脉水平以下多节段（平面）动脉闭塞症是一种较实用的方法,可有效解决自体血管不足和单纯使用人工血管腘动脉以下血管重建通畅率差的问题。     

Midterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass

BACKGROUND: Coronary bypass surgery that provides good long-term graft patency can be performed on the beating heart as a viable alternative to conventional coronary artery bypass grafting (CABG). METHODS: From September 1993 to December 1996, 696 patients underwent CABG on the beating heart at the Ko?uyolu Heart and Research Hospital in Istanbul. Among them, 70 patients were chosen randomly for angiographic assessment of off-pump coronary artery bypass grafting. RESULTS: The interval from operation to angiography varied from 24 to 61 months (mean, 36.1+/-10.9 months). The patency rate of left internal mammary-left anterior descending artery anastomoses was 95.59% (patency achieved in 65 of 68 patients) and of vein grafts was 47.06% (patency achieved in 16 of 34 patients) (p < 0.0001). The patency rates of grafts anastomosed to the left anterior descending artery were significantly higher than the rates of the grafts anastomosed to the other coronary arteries (95.71% versus 45.45%, p < 0.0001). Multivariate analysis showed that graft type (p < 0.0001) and hyperlipidemia (p = 0.023) were significant predictors for graft occlusion. Left ventricular function improved significantly after CABG (p = 0.04). Reintervention (using percutaneous transluminal cardiac angioplasty) and reoperation rates were 0.97% and 1.4%, respectively. CONCLUSIONS: Off-pump coronary artery bypass grafting appears to produce midterm and long-term patency rates that are comparable to those of conventional techniques; that is especially true in cases of arterial conduits and of conduits anastomosed to the left anterior descending artery.     

Coronary artery bypass grafting with the right gastroepiploic artery

The excellent results of coronary artery bypass with the internal mammary artery and the increasing numbers of patients who need coronary reoperations, but for whom conventional bypass conduits are not available, have prompted us to evaluate alternative arterial bypass conduits. The right gastroepiploic artery has been used as a coronary bypass graft in 36 patients (32 men), whose ages ranged from 29 to 71 years. Twenty-two patients had had previous coronary bypass grafting and six of these were undergoing their third bypass operation. The right gastroepiploic artery was used as an in situ graft to the right coronary artery or circumflex branches for 17 patients and as an aorta-coronary ("free") graft in 19 patients, six to the left anterior descending or diagonal, six to the circumflex, and seven to the right coronary artery. In conjunction with right gastroepiploic artery grafting, 16 patients received bilateral internal mammary artery grafts and 17 received one internal mammary artery graft. Histologically, right gastroepiploic artery segments from 18 patients could not be distinguished from internal mammary artery segments, and no evidence of atherosclerosis was found. Two patients died in the hospital, one intraoperatively and one 3 months after the operation, of a perioperative stroke. Perioperative morbidity included wound complication in three and reexploration for bleeding in two. At late follow-up 1 to 38 months after operation, two late deaths had occurred and 21 patients were free of symptoms. Postoperative angiography (postoperative interval 1 week to 13 months) was performed in nine grafts, three in situ grafts to the right coronary artery and six free grafts that included two to the left anterior descending, three to the circumflex, and one to the right coronary artery. All right gastroepiploic artery grafts were patient. The right gastroepiploic artery is an arterial conduit that can be used as an in situ graft to posterior coronary vessels and as a free graft to any coronary arterial system. Early graft patency has been excellent, and the histologic similarity between the right gastroepiploic artery and the internal mammary artery suggest that the long-term results will be favorable.     

A case report of coronary artery bypass grafting with the left internal mammary, the right gastroepiploic, and the inferior epigastric arteries

We performed coronary artery bypass grafting with the left internal mammary artery, right gastroepiploic artery, and inferior epigastric artery on a 60-year-old male. The inferior epigastric artery used as a free graft was placed between the in situ left internal mammary graft proximally and the obtuse marginal branch distally. Both the left internal mammary graft to the left anterior descending artery and the right gastroepiploic artery to the right coronary artery were used as an in situ graft. All grafts were patent two weeks after the operation and the patient was free from angina at three months follow-up period.     

下肢动脉硬化闭塞症侧支循环流出道的解剖学特点及临床应用初探

目的下肢动脉粥样硬化闭塞症（arterial sclerosis obstruction，ASO）末期常无远端流出道，对末期ASO患者膝上截肢的离断标本行血管灌注，通过解剖学研究评估侧支流出道构建的可能性及临床应用前景。方法在10例自愿捐赠的膝上截肢新鲜离体标本上向动脉内灌注红色乳胶，解剖观察胭动脉、胫前动脉、胫后动脉的病理改变，以及这些主干动脉侧支分布的规律。2005年9月-2007年4月，收治5例ASO患者，均为单侧。其中男3例，女2例；年龄68～81岁。均有6个月静息痛病史。下肢DSA示股动脉、胭动脉及分支均不显影，B超示胭动脉及分支基本闭塞，行胭动脉及分支探查、血循环重建术。结果解剖学实验结果：胭动脉、胫后动脉、胫前动脉管壁僵硬，动脉粥样斑块填满管腔。胭动脉及分支发出的侧支中，腓肠动脉开口于主干动脉的几率最大。所有侧支在膝周构建的侧支循环稀疏，而在小腿肌群内可形成相对丰富的侧支循环。临床应用结果：5例手术均顺利，术后皮温逐渐增高，血氧饱和度术前为0，术后6h逐渐达90％～100％。获随访3～12个月，患者感觉下肢症状明显改善，静息痛消失，下肢溃疡逐渐愈合。B超示胭动脉吻合口处血流大部进入侧支循环，远侧胫前、胫后动脉的血流量并不多。结论通过临床解剖发现，侧支流出道的构建是可行的，临床应用结果提示这一方法是解决晚期ASO患者的一种有效途径。     

Isolated femoropopliteal bypass graft for limb salvage after failed tibial reconstruction: a viable alternative to amputation

PURPOSE: Femoropopliteal bypass grafting procedures performed to isolated popliteal arteries after failure of a previous tibial reconstruction were studied. The results were compared with those of a study of primary isolated femoropopliteal bypass grafts (IFPBs). METHODS: IFPBs were only constructed if the uninvolved or patent popliteal segment measured at least 7 cm in length and had at least one major collateral supplying the calf. When IFPB was performed for ischemic lesions, these lesions were usually limited to the digits or small portions of the foot. Forty-seven polytetrafluoroethylene grafts and three autogenous reversed saphenous vein grafts were used. RESULTS: Ankle brachial pressure index (ABI) increased after bypass grafting by a mean of 0.46. Three-year primary life table patency and limb-salvage rates for primary IFPBs were 73% and 86%, respectively. All eight IFPBs performed after failed tibial bypass grafts remained patent for 2 to 44 months, with patients having viable, healed feet. CONCLUSION: In the presence of a suitable popliteal artery and limited tissue necrosis, IFPB can have acceptable patency and limb-salvage rates, even when a polytetrafluoroethylene graft is used. Secondary IFPB can be used to achieve limb salvage after failed tibial bypass grafting.     

Re-use of left internal thoracic artery for redo operation after MIDCAB

We report a case of recycling of left internal thoracic artery (LITA) in situ in reoperation of coronary artery bypass grafting. A 41-year-old male, who has poor-controlled hypercholesterolemia, was bypassed LITA to the left anterior descending artery (LAD) in minimally invasive direct coronary artery bypass (MIDCAB) manner at the other hospital. Four months later, he felt short of breath on effort. Coronary angiogram showed stenoses of the left main trunk and anastomosis site of the LITA. At redo operation, we skeletonised the LITA and reused it in situ to the LAD. Using the skeletonised method for re-harvesting LITA made the graft reach a more distal portion without tension. He is doing well at 18 months after surgery. In selected patients, recycling of the used arterial grafts can reserve other arterial grafts for redo operations in the future.     

Early experience with minimally invasive direct coronary artery bypass grafting with the internal thoracic artery

OBJECTIVE: Minimally invasive direct coronary artery bypass is performed under direct vision without sternotomy or cardiopulmonary bypass. The technique can be used in both primary and reoperative cases by employing the internal thoracic artery to perform arterial revascularization of the anterior surface of the heart. METHODS: Patients were selected who had significant coronary artery disease limited to 1 or 2 coronary distributions on the anterior surface of the heart. Coronary target vessels were grafted with the internal thoracic artery through a small anterior thoracotomy. After partial heparinization the anastomosis was facilitated by local coronary occlusion and handheld stabilization. RESULTS: Between August 1994 and July 1997, 162 patients underwent minimally invasive direct coronary artery bypass grafting with the internal thoracic artery. The left and right internal thoracic arteries were used for grafting of the left anterior descending artery in 142 patients (88%), the proximal right coronary artery in 7 patients (4%), existing saphenous vein grafts in 5 patients (3%), and diagonal branches in 2 patients (1%). Sequential grafting with the left internal thoracic artery was performed in 2 patients (1%) and bilateral internal thoracic artery grafting was performed in 4 patients (3%). Eight patients (4.9%) died within 30 days after the operation, 3 of cardiac causes. Seven additional patients died during the follow-up period. Nine patients (5.6%) required reintervention for graft stenosis or occlusion during follow-up. Of 141 patients seen 2 or more weeks after the operation, 135 (96%) had resolution of their anginal symptoms at a mean follow-up of 12 months (range 0-31 months). CONCLUSIONS: Anterior minimally invasive direct coronary artery bypass grafting with the internal thoracic artery avoids the risks of repeated sternotomy, aortic manipulation, and cardiopulmonary bypass. There was a low rate of reintervention, and patients had excellent resolution of anginal symptoms. Postoperative length of stay was comparatively short, and continued follow-up will be essential to evaluate long-term graft patency and patient survival.     

Benefits accruing to grafting of the right internal thoracic artery to the left anterior descending artery in coronary artery bypass grafting.

OBJECTIVES: We have investigated the effects and outcome from grafting the right internal thoracic artery to the left anterior descending artery in coronary artery bypass grafting. METHODS: We analyzed the findings in 185 patients who underwent coronary artery bypass grafting involving right internal thoracic artery-left anterior descending artery bypass. The survival rate, cardiac events related to the right internal thoracic artery-left anterior descending artery graft, and graft patency were investigated. In cardiac catheterization, the production of nitric oxide from the endothelium of the internal thoracic artery was measured as the plasma nitrite and nitrate levels by the Griess reaction. The reactions to acetylcholine infusion (5 micrograms) in the right internal thoracic artery (n = 4) were compared to those in the left internal thoracic artery (n = 9) grafts. RESULTS: The hospital mortality rate was 0.5%. The actuarial survival rate at 11 years after operation was 98.81%. The rate of freedom from cardiac events at 11 years after operation was 92.08%. The rate of patency of the right internal thoracic artery-left anterior descending artery was 97.0% in 133 patients. Nitric oxide production was calculated as (total nitrite plus nitrate production in response to stimulation by acetylcholine-total nitrite plus nitrate level before acetylcholine load)/(total nitrite plus nitrate level before acetylcholine load). There was no significant difference in changes in plasma concentration in response to acetylcholine stimulation between the right internal thoracic artery-left anterior descending artery and left internal thoracic artery-left anterior descending artery groups (20 +/- 29% versus 5 +/- 10%). CONCLUSIONS: The right internal thoracic artery-left anterior descending artery grafts exhibited good patency and release of nitric oxide in response to acetylcholine loading, similar to left internal thoracic artery-left anterior descending artery grafts.     

Distally-based free vascularized tissue grafts in the lower leg

In the field of orthopaedic surgery, the lower leg is often treated by free vascularized tissue grafts. In performing these grafts for reconstruction of the lower leg, the anterior tibial artery and its venae comitantes are frequently selected as anastomosing recipient vessels. However, due to the deep location of the anterior tibial vessels, it is extremely difficult to accomplish antegrade microsurgical anastomoses between the donor vessels and the anterior tibial vessels. This technical difficulty often leads to the possibility of immediate postoperative arterial and venous occlusion. To resolve this problem, the idea of a reverse-flow island flap has been applied to the free vascularized tissue grafts for reconstruction of the lower leg, based on both artery and vein reconstructed with retrograde blood flow. To evaluate clinical outcomes of the procedure mentioned, the postoperative results of 14 patients were reviewed. The free vascularized grafts consisted of seven vascularized fibular grafts with peroneal flaps, six vascularized latissimus dorsi myocutaneous flaps, and one vascularized groin flap. Venous congestion of the flap was not observed and all flaps survived. Bone union was obtained in seven patients treated with vascularized fibular grafts. There were no serious postoperative complications. Distally-based free vascularized tissue grafts in the lower leg are useful procedures in reconstruction of massive bone defects and osteomyelitis of the tibia, and for skin defects on the anterior aspect of the lower leg.     

Benefits accruing to grafting of the right internal thoracic artery to the left anterior descending artery in coronary artery bypass grafting

Objectives: We have investigated the effects and outcome from grafting the right internal thoracic artery to the left anterior descending artery in coronary artery bypass grafting.Methods: We analyzed the findings in 185 patients who underwent coronary artery bypass grafting involving right internal thoracic artery-left anterior descending artery bypass. The survival rate, cardiac events related to the right internal thoracic artery-left anterior descending artery graft, and graft patency were investigated. In cardiac catheterization, the production of nitric oxide from the endothelium of the internal thoracic artery was measured as the plasma nitrite and nitrate levels by the Griess reaction. The reactions to acetylcholine infusion (5 μg) in the right internal thoracic artery (n = 4) were compared to those in the left internal thoracic artery (n = 9) grafts.Results: The hospital mortality rate was 0.5%. The actuarial survival rate at 11 years after operation was 98.81%. The rate of freedom from cardiac events at 11 years after operation was 92.08%. The rate of patency of the right internal thoracic artery-left anterior descending artery was 97.0% in 133 patients. Nitric oxide production was calculated as (total nitrite plus nitrate production in response to stimulation by acetylcholine-total nitrite plus nitrate level before acetylcholine load) / (total nitrite plus nitrate level before acetylcholine load). There was no significant difference in changes in plasma concentration in response to acetylcholine stimulation between the right internal thoracic artery-left anterior descending artery and left internal thoracic artery-left anterior descending artery groups (20 ± 29% versus 5 ± 10%).Conclusions: The right internal thoracic artery-left anterior descending artery grafts exhibited good patency and release of nitric oxide in response to acetylcholine loading, similar to left internal thoracic artery-left anterior descending artery grafts.     

血栓闭塞性脉管炎合并动脉硬化闭塞导致下肢缺血的手术治疗

目的 探讨下肢血栓闭塞性脉管炎(thmmboangiitis obliterans,TAO)合并动脉硬化闭塞症(arteriosclerosis obliterans,ASO)手术治疗效果.方法 回顾性分析2007年治疗的TAO合并ASO 6例患者的资料.2例行腹主动脉切开取栓+内膜剥脱+腹主动脉-股深动脉人工血管旁路移植-胭动脉人工血管-小腿动脉自体大隐静脉旁路移植术,1例行腹主动脉切开取栓+内膜剥脱+腹主动脉-右股深动脉人工血管旁路移植-膝下胭动脉人工血管旁路移植术;1例行左髂总动脉-左股深动脉人工血管旁路移植一胫前动脉自体大隐静脉原位移植术,1例行左侧人工血管切开取栓+左股深动脉成形-膝下腘动脉人工血管旁路移植术,1例行右股总动脉-左股总动脉人工血管旁路移植-胫后动脉自体大隐静脉旁路移植术.结果 5例患者术后恢复顺利,1例于术后当天出现股动脉-腘动脉人工血管和远段的大隐静脉桥血栓形成,立即再次手术行人工血管和大隐静脉切开取栓术,并同时行胫后动静脉吻合.6例患者均痊愈出院,无死亡病例.5例患者的下肢远端静息痛完全缓解,1例部分缓解.足部溃疡的2例创面明显缩小,无感染发生.所有患者得到随访,平均随访为6.5个月,3例足部溃疡愈合.1例术后3个月出现左股部切口感染,最终行膝上截肢处理,残端一期愈合.其他5例患者的移植血管通畅,症状缓解.结论 对TAO合并ASO患者如果手术治疗方式恰当,可以取得比较好的疗效.     

Assessment of saphenous vein grafts flow by Doppler echocardiography

In an effort to evaluate flow characteristics of the saphenous vein grafts (SVG) after coronary artery bypass grafting, we performed duplex scanning of SVG which were anastomosed to the left anterior descending artery in 12 patients, and compared those indexes with 34 internal thoracic artery grafts (ITAG). The SVG were observed with a 7.5 MHz duplex scanner through the anterior intercostal space. The diameter of the vessel, systolic peak velocity, and diastolic peak velocity were recorded in both groups, and systolic flow volume, diastolic flow volume, and velocity ratio were calculated. The systolic and diastolic peak velocity of SVG were predominantly lower than ITAG. No difference in the diameter and flow ratio could not be demonstrated between 2 groups. The flow volume of SVG were also predominantly lower than that of ITAG throughout cardiac cycle. This study reveals that advanced stenotic change were caused in the SVG group and suggest the occurrence of vein grafts disease long after coronary artery bypass grafting.     

Internal mammary artery grafting. Clinical results, patency rates, and long-term survival in 833 patients

This report reviews 833 patients who underwent internal mammary artery grafting alone or with vein grafts between 1968 and 1981. Use of the internal mammary artery was indicated in young or middle-aged patients with the following characteristics: a significant lesion of the proximal left anterior descending artery or its diagonal branch alone (70.1%) or combined with diffuse atherosclerosis (19.9%) or a small caliber (3.4%); absent or unsuitable veins for grafting (5.5%); atherosclerosis or an aneurysm of the ascending aorta (0.6%); and failure of previous vein grafts (0.5%). The left anterior descending artery system was grafted by the left internal mammary artery in 53.2%, and the arterial graft was complimented by vein grafts in 2.6%. In 45.2% of the patients, grafts of the left anterior descending artery by the left internal mammary artery were supplemented by vein grafts to the right coronary artery (23.8%), to the circumflex artery (15.2%), or to both (6.2%). The overall operative mortality was 2.2%. It rose to 16.7% with associated cardiac procedures and to 18.5% in patients who were in New York Heart Association Class IV. If these two high-risk categories of patients are excluded, the perioperative death rate in the remaining 750 was only 0.4%. Of the 815 patients who survived the perioperative period (mean 53.1 months follow-up), 63.1% were relieved of angina and 83.4% were in Class I or II of the New York Heart Association, as compared to 27.4% before the operation. At cardiac recatheterization (mean 18.9 months), 87.9% of the internal mammary artery grafts and 63.3% of the vein grafts were patent (p less than 0.05). The cumulative actuarial 10 year survival rate was 88.6% +/- 1.3%.     

Are peroneal artery bypass grafts hemodynamically inferior to other tibial artery bypass grafts?

Purpose: Many authors have reported excellent long-term patency rates of peroneal artery bypasses. It has been suggested, however, that the hemodynamic result of the peroneal bypass is inferior to that of other infrapopliteal artery bypasses, making it suboptimal in patients with forefoot ischemic tissue loss. A retrospective review of 118 recent infrainguinal vein grafts (36 peroneal, 27 anterior tibial, 35 posterior tibial, 20 popliteal) was undertaken to assess and compare the hemodynamic results for each group.Methods: We reviewed the hemodynamic results of 36 peroneal bypass grafts assessed by preoperative and postoperative ankle-brachial index and transmetatarsal pulse volume recording, duplex scan-derived distal graft peak systolic flow velocity, and intraoperatively measured outflow resistance. These results were compared with a concurrent series of anterior tibial, posterior tibial, and popliteal artery bypass grafts. All but one of the infrapopliteal bypass grafts were performed for limb salvage, and 65% of patients had ischemic ulcerations or gangrene.Results: There was no difference in postoperative ankle-brachial index, postoperative transmetatarsal pulse volume recording, peak systolic flow velocity, or measured outflow resistance among the four different outflow groups. All patients with peroneal bypass grafts had healed wounds within a mean follow-up period of 17 months. There were no hemodynamic failures.Conclusion: Peroneal artery bypass grafts achieved hemodynamic results equivalent to anterior tibial, posterior tibial, and popliteal artery bypass grafts. (J VASC SURG 1994;19:964–9.)     

Long-term evaluation of composite sequential bypass for limb-threatening ischemia.

When sufficient vein for a completely autogenous femorotibial artery bypass is not available, composite sequential grafting by using vein combined with polytetrafluoroethylene material is a surgical option. This study reviews what is currently the largest collection of these grafts and focuses on technical aspects and long-term patency characteristics. During a 7-year period 67 composite sequential bypasses were used to manage rest pain (38), ulcer (18), or gangrene (11) in 62 patients (mean age, 66 years). Fifty-two percent were men, and 51% had diabetes. This method was used as a primary reconstruction in 30, a second bypass in 16, and in 21 it was used after multiple other failed bypasses. Femoral to above-knee popliteal (44) and below-knee popliteal (23) 6 mm polytetrafluoroethylene grafts were placed. Then extensions of greater saphenous (57) or lesser saphenous (10) vein were anastomosed to the anterior tibial (19), posterior tibial (26), or peroneal (22) arteries. Fifty-three percent were maintained on long-term warfarin (Coumadin) anticoagulation, and 33% were maintained on aspirin. No deaths occurred in the perioperative period. Bypass patency was ascertained by a Doppler pressure and waveform analysis, with mean follow-up of patency or to the time of graft failure of 33 months (1 to 91 months). Three-year patient survival was 72%. Cumulative life-table primary patency of 72% (1-year), 64% (2-year), and 48% (3-year) was calculated. Two grafts are functioning 7 years after placement. Limb salvage was 84% at 2 years and 70% at 4 years. At the time of failure, five grafts retained a patent venous bypass segment, which allowed prompt reconstruction of the proximal portion. In a comparison of grafts with early failure and those with long-term patency, the SVS/ISCVS runoff score, vein diameter, tibial artery diameter, and coagulation status were similar. However, patients with the popliteal anastomosis above the knee had 2-year patency of 72% compared with 46% for those with below-knee anastomoses. This technique, when possible, appears preferable to an all prosthetic tibial bypass.     

A case of bilateral internal thoracic artery bypass grafting in sudden death survivor with multivessel coronary spasms

We report a 58-year-old male with a history of cardiac arrest due to coronary artery spasm, preoperative coronary arteriograms showed multivessel coronary spasm after the administration of ergonovine maleate associated with triple vessel fixed stenotic lesions. Under the use of cold diltiazem potassium-blood cardioplegic solution to prevent perioperative coronary spasm, coronary artery bypass grafting was performed. The right internal thoracic artery (ITA) was anastomosed to the left anterior descending artery and the left ITA to the circumflex artery. A saphenous vein graft was anastomosed to the right coronary artery. The postoperative course was uneventful. In postoperative coronary angiography with ergonovine stimulation, neither ITA grafts showed spastic changes, and the coronary artery distal to the anastomotic sites were well perfused through the ITA grafts. The patient has been free of angina without administration of calcium antagonist and been doing well for 2 years and 5 months since the operation.     

Multiple minimally invasive direct coronary artery bypass grafting for the complete revascularization of the left ventricle.

BACKGROUND: Single-vessel coronary artery bypass grafting of the left internal mammary artery to the left anterior descending coronary artery using a minithoracotomy has been shown to produce excellent results with a very low mortality rate. However, this procedure cannot be used in patients with double- or triple-vessel disease. Our goal was to develop a minimally invasive direct coronary artery bypass grafting without cardiopulmonary bypass for total revascularization of the left ventricle using multiple arterial grafts. METHODS: Limited lateral thoracotomy was performed in the fourth or fifth intercostal spaces, exposing the left anterior descending coronary artery and left circumflex coronary artery. Two or three arterial grafts were harvested. Revascularization of the left anterior descending coronary artery and the left circumflex coronary artery were performed in 20 patients without cardiopulmonary bypass through the limited lateral thoracotomy using complex performed arterial grafts. In 4 patients, triple- and quadruple-vessel grafting was performed. RESULTS: The mean coronary cross-clamp time was 14.5+/-4.0 minutes for the left anterior descending coronary artery and 16.8+/-5.1 minutes for the left circumflex coronary artery. No early deaths or postoperative complications occurred. There were no late deaths or angina during the mean follow-up of 7.0 months (range, 2 to 22 months). Postoperative coronary angiography demonstrated widely patent grafts in all patients. CONCLUSIONS: Minimally invasive approach through a limited thoracotomy in multiple coronary artery bypass graftings are technically feasible and may be an alternative approach in the complete revascularization of the left ventricle. Mechanical immobilization of the coronary artery enhances early graft patency and is an essential part of this procedure.     

Multivessel coronary revascularization without saphenous vein: long-term results of bilateral internal mammary artery grafting

When the saphenous vein is absent or inadequate, options for multivessel coronary revascularization include bilateral mammary artery grafting and the use of conduits of unproven durability (arm vein, homologous umbilical vein, prosthetic graft). To evaluate the long-term effectiveness of bilateral mammary artery grafting, we reviewed the cases of 76 consecutive patients with multivessel disease (33 with two-vessel disease, 43 with three-vessel disease) who underwent revascularization with bilateral mammary artery grafts only during the period from 1971 to 1980. No hospital deaths occurred. Thirty-three free and 119 in situ grafts were used. Late follow-up was complete, ranging from 12 to 132 months (mean interval, 67 months) and revealed improvement by at least one New York Heart Association functional class in 59 of 71 survivors. Postoperative arteriograms (mean interval, 26 months) of 55 grafts in 28 patients showed that 49 grafts were patent (89%). Five late deaths (2 noncardiac) occurred. Actuarial survival was 97.2% to seven years and 90.2% at nine years after operation. Bilateral mammary artery grafting yielded excellent graft patency, relief of symptoms, and long-term survival. When saphenous vein is unsuitable for grafting, bilateral mammary artery grafts should be utilized before other conduits are considered.